Surety One, Inc. www.suretyone.com Underwriting@SuretyOne.com 5 W Hargett St, 4th Floor, Raleigh NC 27601 T: 800 373 2804 F: 919 834 7039 404 Av De La Constitución, #708, San Juan PR 00901 T: 787 333 0222 FINANCIAL INSTITUTION BOND APPLICATION Standard Form No. 24 for Commercial Banks, Savings Banks, and Savings and Loan Associations BOND Type Primary Excess Concurrent Co-surety Coinsured Other: Aggregate Limit of Liability Name of Prior Carrier Effective Date End Date APPLICANT Name of Bank / Association (herein called "Insured") Date Established Address City State Zip Code Insured is a: Commercial Bank Savings Bank Savings and Loan Association Other: List all Insureds (including Employee Benefit Plans) Employees & Locations Total number of salaried officers, employees, retained attorneys, and persons provided by employment contractors Total number of banking locations (other than the Home Office of the first Named Insured) in the US, Canada, Puerto Rico, and Virgin Islands Total number of limited banking facilities in the US, Canada, Puerto Rico, and Virgin Islands Total number of non-banking locations in the US, Canada, Puerto Rico, and Virgin Islands Total number of banking locations, limited banking facilities, and non-banking locations outside of the US, Canada, Puerto Rico, and Virgin Islands List all outside locations and facilities of Insured Assets As of latest December 31: Total Assets Total Deposits (Commercial Banks only) Total Loans & Discounts (Commercial Banks only) As of latest June 30: Total Assets Total Deposits (Commercial Banks only) Total Loans & Discounts (Commercial Banks only) Page 1
COVERAGES REQUESTED Include Insuring Agreement (D) Forgery or Alteration Coverage? Include Insuring Agreement (E) Securities Coverage? Include Trading Loss Coverage? Include Extortion Threats to Person Coverage? If Yes, list all Locations to be excluded: If Yes, are checking accounts permitted?* If Yes, include Loan Participation Coverage? Include Extortion Threats to Property Coverage? If Yes, list all Locations to be excluded: Include Fraudulent Real Property Mortgage Coverage? Include Audit Expense Coverage? Include Unattended Automated Teller Machine (ATM) Coverage? If Yes, list all Locations to be excluded: Note: This Coverage is for Savings and Loan Associations only. If Yes, number of locations to be covered: Include Computer Systems Fraud Coverage? If Yes, complete all fields within this section. Number of independent software contractors authorized to design, implement, or service programs for Insured's Computer Systems Is access permitted to Insured's Computer Systems by customers or other outside parties (e.g. by computer, terminal, touchtone telephone keypad, etc.; excluding ATM)? Number of Automated Teller Machines (ATMs) operated (owned or leased) by Insured Include Coverage for: Automated Clearing Houses using Federal Reserve Computer Facilities Fed Wire CHIPS SWIFT Other (non-atm) List all shared or other participatory ATM Systems to include in Coverage If Other (non-atm), list all Other (non-atm) Computer Systems to be Covered Include Coverage of Tested telex or similar Tested communication means? Include Voice-Initiated Transfer Fraud Coverage? Include Telefacsimile Transfer Fraud Coverage? Include Coverage on businesses engaged in the data processing of Insured's checks or other accounting records? Include Servicing Contractors Coverage? If Yes, call-back threshold to originator of an instruction: If Yes, call-back threshold to originator of an instruction: If Yes, list Name and Location of each data processor Note: This Coverage requires purchase of Computer Systems Fraud Coverage Note: This Coverage requires purchase of Computer Systems Fraud Coverage Note: Servicing Contractors service your real estate mortgages or home modernization loans, or manage your real property. If Yes, list Names and Locations of Servicing Contractors to be Covered If Yes, list Names and Locations of Servicing Contractors to be Excluded * This field applies only to Savings Banks, and Savings and Loan Associations Insured's Computer Systems include all Computer Systems operated, whether owned or leased, by Insured. Commercial Banks, Savings Banks, Savings and Loan Associations, or industry service organizations formed by any of them, may be excluded. Page 2
Include Coverage on Issuers of Register Checks or Personal Money Orders? If Yes, list Names and Locations of each Issuer Note: This Coverage is for Commercial Banks only. Include Coverage on Insured's appointed or elected Agents (including persons, partnerships, and corporations; excluding servicing contractors and data processors) performing any act or service in connection with the ordinary conduct of Insured's business? Is Insured a direct participant in a depository for the central handling of securities? If Yes, list Name, Location, and Single Loss Limit of Liability of each Agent If Yes, list Name and Location of each depository Note: This Coverage is for Savings Banks and Savings and Loan Associations only. Indicate if Insured is a seller or servicer of any secondary market mortgages Freddie Mac Fannie Mae Ginnie Mae None Other: Single-Loss Deductible for all Coverages except Insuring Agreements (D) and (E), Extortion, and Unattended ATMs Single-Loss Deductible for Insuring Agreement (D) Forgery or Alteration Single-Loss Deductible for Insuring Agreement (E) Securities Single-Loss Deductible for Extortion Threats to Persons Single-Loss Deductible for Extortion Threats to Property Single-Loss Deductible for Unattended ATMs Note: Must be greater than or equal to the Deductible on the Basic Bond Coverage. Note: Must be greater than or equal to the Deductible on the Basic Bond Coverage. Note: May be any amount. Note: May be any amount. Note: May be any amount. If Coverage is being written on an excess, concurrent, or co-surety basis, list Names of other Carriers, and Bond Limits. If co-surety, also list Percentage Participations If Coverage is being written on a coinsurance basis, declare Insured's Percentage Participation % Are Insured's deposits insured by the Federal Deposit Inusrance Corporation (FDIC)? Note: Insured may assume a participation between 5% and 25%. Audit Protocols & Internal Controls Is Insured audited annually by an independent CPA? If Insured does not have certified annual audits, explain the scope of the CPA's examination If Yes, is it complete and in accordance with generally accepted auditing standards, and so certified? Is the audit report rendered directly to the Board of Directors? Is there a continuous internal audit by an Internal Audit Department? Name and Location of CPA If Yes, are monthly reports rendered directly to the Board of Directors? Is there direct verification of at least 20% of all deposit accounts, and direct verification of at least 20% of all loan accounts? Does Insured require annual vacations of at least two consecutive weeks for all officers and employees? Does Insured have a formal, planned program requiring the rotation of duties of key personnel without prior notice thereof? Does Insured have a formal planned program requiring the segregation of duties so that no single transaction can be fully controlled from origination to posting by one person? If No, explain If No, explain If No, explain Completion Date of last audit by CPA Page 3
Miscellaneous Date of last examination by State authorities Date of last examination by Federal authorities Was there any criticism of your operations in either the last State or Federal examination? If Yes, explain Has there been any change in ownership or management within the past three years? Has any insurance been declined or canceled during the past three years? If Yes, explain If Yes, explain Have any losses (whether reimbursed or not) been sustained during the past three years? If Yes, list the details of each Loss below. Date of Loss Type of Loss Location of Loss Amount of Loss Amount Recovered from Insurance Amount Recovered from other than Insurance Amount of Loss Pending FRAUD STATEMENTS ALABAMA: "Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof." ARKANSAS: ''Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.'' COLORADO: ''It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.'' DISTRICT OF COLUMBIA: ''WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.'' FLORIDA: ''Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.'' HAWAII: ''For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.'' KENTUCKY: ''Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.'' LOUISIANA: ''Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.'' MAINE: ''It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.'' MARYLAND: ''Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison". NEW JERSEY: ''Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.'' NEW MEXICO: "Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties." Page 4
NEW YORK: ''Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.'' OHIO: ''Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.'' OKLAHOMA: ''WARNING: Any person who knowingly, and with intent to injury, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.'' PENNSYLVANIA: ''Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.'' RHODE ISLAND: "Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison." VIRGINIA: ''It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.'' WASHINGTON: ''It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.'' WEST VIRGINIA: "Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison." PUERTO RICO: "Any person who knowingly, and with the intention of defrauding, presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars (5,000) and not more than ten thousand dollars (10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years. If extenuating circumstances are present, it may be reduced to a minimum of two (2) years." TENNESSEE: ''It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.'' All particulars herein are declared to be true and complete to the best of the Applicant's knowledge, and no information has been withheld or suppressed, and the Applicant agrees that this application and the terms and conditions of the policy in use by the insurer shall be the basis of any contract between the Applicant and the insurer. The Applicant hereby authorize the insurer to investigate all or any qualifications or statements contained herein. Applicant Name: Date: Applicant Signature: This application does not commit the insurer to any liability, nor does it make the applicant liable for any premium unless and until the insurer agrees to effect this insurance. Page 5
Surety One, Inc. www.suretyone.com Underwriting@SuretyOne.com 5 W Hargett St, 4th Floor, Raleigh NC 27601 T: 800 373 2804 F: 919 834 7039 404 Av De La Constitución, #708, San Juan PR 00901 T: 787 333 0222 WE'VE MADE IT EASY FOR YOU TO COMPLETE AND SUBMIT THIS APPLICATION TWO EASY WAYS TO COMPLETE THIS APPLICATION PRINT OR DIGITAL For PRINT completion: 1. Print this PDF. 2. Complete the application with a black pen by legibly writing your responses in the applicable fields. 3. Use one of the following ways to submit the completed application: a. Scan, then email the pages to Underwriting@SuretyOne.com or your assigned underwriter b. Mail the pages to our Raleigh NC address (listed above) c. Fax the pages to 919 834 7039 For DIGITAL completion: 1. Download this PDF to your computer. 2. Open the file in a PDF editor, such as Adobe Acrobat Reader DC (available for free here: https://get.adobe.com/reader/). 3. Complete the application by typing and clicking your responses in the applicable fields. 4. Save your updated file to your computer by going to File > Save as 5. Use one of the following ways to submit the completed application: a. Attach the PDF to an email, and send to Underwriting@SuretyOne.com or to your assigned underwriter b. Upload the PDF to the form on www.suretyone.com/contact-us Note: Incomplete applications may result in processing delays. Fidelity bonds, also known as Commercial Crime Policies, are written to protect organizations from the impact of an employee's dishonest acts. Surety One, Inc. offers very broad forms for both domestic and international business operations, following the S.F.A.A. formats which include: Employee theft Depositors forgery or alteration Theft, disappearance and/or destruction of money and securities Robbery and safe burglary Computer Crime (theft, funds transfer fraud, etc.) Counterfeit currency/money orders The basic coverage forms can be expanded by negotiated endorsement. Do you have an "outside of the box" or "non-standard" fidelity risk? No problem. Do you need a special fidelity bond manuscripted for your particular client? Surety One, Inc. can help. Page 6